Elderly prescribing

Elderly patients prescribed one of the dopamine receptor agonists are monitored closely for which of the following adverse reactions ... 

Another key feature of the thiazide-type diuretics is their limited efficacy in patients whose estimated renal function is reduced, such as the elderly. For example, patients with estimates of reduced renal function, such as those with a glomerular filtration rate (GFR) below 30 mL/minute, should be considered for more potent loop type diuretics such as furosemide. Clinicians often fail to either reconsider the role of thiazide diuretics prescribed to individuals whose renal function has been declining or fail to recognize the likely prevalence of renal compromise in the elderly to begin with. 

Vigilance for drug-drug interactions is required because of the greater number of medications prescribed to elderly patients and enhanced sensitivity to adverse effects. Pharmacokinetic interactions include metabolic enzyme induction or inhibition and protein binding displacement interactions (e.g., divalproex and warfarin). Pharmacodynamic interactions include additive sedation and cognitive toxicity, which increases risk of falls and other impairments. 

The common causes of thyrotoxicosis are shown in Table 41-6.29,30 Thyrotoxicosis can be related to the presence or absence of excess hormone production (hyperthyroidism). Graves disease is the most common cause of hyperthyroidism. Thyrotoxicosis in the elderly is more likely due to toxic thyroid nodules or multinodular goiter than to Graves disease. Excessive intake of thyroid hormone may be due to overtreatment with prescribed therapy. Surreptitious use of thyroid hormones also may occur, especially in health professionals or as a self-remedy for obesity. Thyroid hormones can be obtained easily without a prescription from health food stores or Internet sources. 

These differences may become particularly germane if co-prescribing with some antipsychotics is undertaken. For example, in certain individuals, combinations of clozapine with benzodiazepines may lead to unexpected adverse events, including delirium and augmented respiratory depression (Jackson, Markowitz Brewer-ton, 1995 Grohmann et al, 1989). Presumably if there are additive or synergistic effects of ethnicity on clearance of one or both substances, adverse events may be enhanced. Similar interactions are theoretically possible with olanzapine, as adverse interactions have been described between olanzapine and benzodiazepines, at least in the elderly (Kryzhanovskaya etal, 2006). 

Huang, W. F. Lai, I. C. (2005). Patterns of sleep - related medications prescribed to elderly outpatients with insomnia in Taiwan. Drugs Aging, 22( 11), 957-65. 

Most of those involved in health care administration agree that elderly patients are the primary consumers of drug products. The actual extent to which this occurs is shown quite clearly in Fig. 1, which lists by age group the distribution in the United States of the drug mentions those medications that have been prescribed, recommended or given in any medical setting... 

Liquids and Suspensions. Most liquid formulations are not packaged in unit-dosage form. Therefore, before administration, the proper amount of medication to be taken for each dose must be measured. This additional requirement may compound any difficulties a patient may have in following a prescribed schedule. Patients suffering from visual impairment, arthritis, or tremors associated with neurological disorders are particularly likely to become frustrated with this type of formulation. Visual impairments make it difficult, if not impossible, for many elderly patients to measure the prescribed amounts of medication accurately. Impaired dexterity, owing to tremors or arthritis, may have effects on a patient s ability to hold both a spoon and a bottle at the same time while pouring out the desired amount of liquid. 

J. Williamson, R. G. Smith, and L. E. Burley, Drugs and safer prescribing, in Primary Care of the Elderly A Practical Approach, IOP Publishing, London, 1987. 

In the elderly, doses should be low, and short-elimination half-life agents prescribed. 

Training of prescribes but also all staff in the elderly care, Evidence Based Medicine, Computerised Prescriber Order Entry, Educational Outreach, inappropriate medications, documentation of clinical benefits, risk medications, drug interactions, pharmacological alterations with age. 

Horne R and Weinman J (1999) Patients beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res 47(6) 555-567 Kannisto V, Lauritsen J, Thatcher AR et al. (1994) Reductions in mortality at advanced age several decades of evidence from 27 countries. Population and development review 20(4) 793-810 Lazarou J, Pomeranz BH, Corey PN (1998) Incidence of adverse drug reactions in hospitalized patients a meta- analysis of prospective studies. JAMA 279(15) 1200-1205 LeSage J (1991) Polypharmacy in geriatric patients. Nurs Clin North Am 26(2) 273-290 Pitkala KH, Strandberg TE, Tilvis RS (2001) Is it possible to reduce polypharmacy in the elderly ... 

A large and growing number of older people across the world suffer from schizophrenia. Recommendations for their treatment are largely based on data extrapolated from studies of the use of antipsychotic medications in younger populations. In addition most manufacturers of such medications recommend prescription of reduced doses to the elderly. The evidence base for these assumptions is unclear and raises obvious questions regarding the appropriateness of such prescribing practice. 

Antipsychotics may be widely used in the treatment of elderly people with schizophrenia, however, based on this systematic review, there are little robust data available to guide the clinician with respect to the most appropriate drug to prescribe. Clearly reported large short, medium and long-term randomised controlled trials with participants, interventions and primary outcomes that are familiar to those wishing to help elderly people with schizophrenia are long overdue. 

Having more than one prescriber increases the risk of inappropriate drug use (Piecoro et al. 2000, Dhalla et al. 2002). Thus, it is important that frail elderly have a physician that has knowledge of the patient s entire pharmacotherapy. It also emphasises the need for communication between different care givers. 

Impairment of memory, delirium and immobility are some of the adverse dmg reactions from benzodiazepines. Elderly patients in nursing homes often receive benzodiazepines inappropriately (Oborne et al. 2003). The frailest elderly, who are most susceptible to ADR from benzodiazepines, use these drugs and often for long term. In a Japanese study it was shown that benzodiazepines were prescribed for longer terms as patient age increased (Nomura et al. 2007). Sometimes elderly patients in nursing homes are treated with benzodiazepines without actually talking to their nurse or physician (Holmquist et al. 2005). This makes it hard evaluate the treatment. 

The use of benzodiazepines should be avoided. There are other safer pharmacological alternatives. Benzodiazepine withdrawal may play a role in the occurrence of delirium in the elderly. Other withdrawal symptoms include tremor, agitation, insomnia and seizures (Turnheim 2003). Thus, when there is long-term use of benzodiazepines abrupt discontinuation might be difficult. Discontinuation should however not be withheld but done slowly and step-wise. If benzodiazepines are used in the elderly, short-acting benzodiazepines such as oxazepam are preferred, because they do not accumulate in the elderly to the same extent (Kompoliti and Goetz 1998). If short-acting benzodiazepines are used they should be prescribed with caution, at low doses, and for short periods. As with all pharmacotherapy the effects should be evaluated. Benzodiazepines are sometimes used as a behavioural control. One should always ask if this use is for the benefit of staff or the benefit of the patient. The presence of staff may be sufficient for behavioural control. 

Flaherty 1H (1998) Psychotherapeutic agents in older adults. Commonly prescribed and over- the-counter remedies causes of confusion. Clin Geriatr Med 14(1) 101-127 Gallagher P, Barry P, O Mahony D (2007) Inappropriate prescribing in the elderly. 1 Clin Pharm Ther32(2) 113-121... 

The increased risk of renal failure in the elderly must be considered when prescribing dmgs that are dependent on the renal function for excretion... 

Several of the individual problems and risks increasing and cumulating the risk for morbidity and mortality in the elderly are presented in this book. Each of them is presented in more detail elsewhere. Special attention should be given to patients with severe diseases, polypharmacy, high-alert medications, several prescribers, several acute hospital admissions, and low compliance. It is important to understand that the problems and risks are interconnected. One problem lead to another in a cascade, where the net benefit to harm relation, might be negative. 

---